Nokea
The nurse is supervising a student nurse on the oncology unit who is providing care for a client with neutropenic precautions. Which action by the student nurse requires intervention by the supervising nurse?
- A. Vital signs, including temperature, are monitored every 4 hours.
- B. The student nurse inspects the client's mouth at least every 8 hours.
- C. The student nurse delivers a potted plant to the room sent by the client's family.
- D. The student nurse washes her hands before performing client care or touching client belongings.
Correct Answer: C
Rationale: Potted plants pose an infection risk (e.g., mold) for neutropenic clients and are prohibited. Other actions are appropriate.
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A client with $B$ positive blood is scheduled for a transfusion of whole blood. Which finding requires nursing intervention?
- A. The available blood has been banked for 2 weeks.
- B. The blood available for transfusion is Rh negative.
- C. The client has a peripheral IV of D5 $1 / 2$ normal saline.
- D. The blood available for transfusion is type 0 positive.
Correct Answer: B
Rationale: Transfusing Rh-negative blood to an Rh-positive client can cause incompatibility reactions, requiring intervention to ensure Rh compatibility.
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
- A. The bladder fills more rapidly because of the medication used for the epidural.
- B. Her level of consciousness is such that she is in a trancelike state.
- C. The sensation of the bladder filling is diminished or lost.
- D. She is embarrassed to ask for the bedpan that frequently.
Correct Answer: C
Rationale: Epidural anesthesia can reduce bladder sensation, necessitating frequent catheterization to prevent overdistension.
A client with AIDS has impaired nutrition because of diarrhea. Which diet selection by the client would indicate a need for further teaching of foods that can worsen the diarrhea?
- A. Tossed salad
- B. Baked chicken
- C. Broiled fish
- D. Steamed rice
Correct Answer: A
Rationale: Raw vegetables in a tossed salad can exacerbate diarrhea in AIDS patients. Baked chicken, broiled fish, and steamed rice are easier to digest and less likely to worsen diarrhea.
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding
- B. Report the finding to the doctor
- C. Prepare the client for a C-section
- D. Continue primary care as prescribed
Correct Answer: B
Rationale: A papular lesion on the perineum during labor could indicate an infectious process (e.g., herpes), so reporting it to the doctor is the most appropriate initial action.
A labor and delivery nurse is caring for a newborn baby whose mother was a regular cocaine user during the entire pregnancy (prenatal cocaine exposure). The nurse expects the newborn to
- A. present with irritability, trouble sleeping, and a shrill cry.
- B. present with lethargy, poor muscle tone, and inability to cry.
- C. require pharmaceutical support for cocaine withdrawal.
- D. benefit from a regular breastfeeding schedule.
Correct Answer: A
Rationale: Prenatal cocaine exposure causes neonatal irritability, sleep disturbances, and a shrill cry due to central nervous system stimulation.